NPIMap

Organization Active NPI

Saint Thomas River Park Hospital, LLC

Doing business as Ascension Medical Group Saint Thomas Woodlee Family Practice

  • Rural Health Clinic/Center
  • McMinnville, TN
National Provider Identifier
1063002202
Registry record updated Jan 21, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
SAINT THOMAS RIVER PARK HOSPITAL, LLC
Doing business as
Ascension Medical Group Saint Thomas Woodlee Family Practice
Practice address
155 Health Way Ste 2
McMinnville, TN 37110-2668
Phone
(931) 473-4214
NPI assigned
Jan 21, 2021
Last updated
Jan 21, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
SAINT THOMAS RIVER PARK HOSPITAL, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jan 21, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Candace Garrett
Title
Manager of Business Operations
Phone
(615) 290-7184

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

155 Health Way Ste 2
McMinnville, TN 37110-2668

Mailing address

300 20TH Ave N Ste 403
Nashville, TN 37203-5180
Phone (615) 289-3257

Other names 1

  • Ascension Medical Group Saint Thomas Woodlee Family Practice Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210317000135 TN Part A Provider - Rural Health Clinic 7214246156 Practice locations: McMinnville, TN

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1063002202. Details of each certification follow.

Rural health clinic certification: CCN 443473

Legal name
SAINT THOMAS RIVER PARK HOSPITAL, LLC
Doing business as
AMG SAINT THOMAS WOODLEE FAMILY PRACTICE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 30, 2021
Last certification
Jun 30, 2021
Ownership / control type
2B
Organization structure
LLCNon-profit
Incorporated
May 15, 2015 in TN
Enrollment address
155 Health Way
Ste 2
McMinnville, TN 37110-2668
Related CCNs
440151

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 5

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
44D0916339Saint Thomas River Park Hospital, LLC155 Health Way, Suite 2, MC Minnville, TN 37110Provider-performed microscopyApr 5, 2027

National Provider Directory

National Provider Directory
Tax ID family
Saint Thomas River Park Hospital LLC13 organizations share this tax ID, including this one
Part of
Saint Thomas River Park Hospital LLC

Other organizations with this tax ID 12

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 4

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Brandon Williams Individual Corporate DirectorCfo Oct 31, 2022
Lynn Dion Miller Individual W-2 Managing EmployeeDirector Mar 10, 2021 100%
Saint Thomas River Park Hospital, LLC Organization, McMinnville, TN LLC, Non-profit 5% Or Greater Direct Ownership Interest Mar 10, 2021 100%
Lisa Davis Individual Corporate OfficerCfo Mar 10, 2021 100%

Owners & managing parties with NPI records 5

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 3

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Amg Saint Thomas Sparta Primary CareSparta, TN, CCN 443476 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Mar 10, 2021
Ascension Saint Thomas River ParkMcMinnville, TN, CCN 443475 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Mar 10, 2021
Amg Saint Thomas Cookeville Primary CareCookeville, TN, CCN 443474 Rural health clinic 5% Or Greater Direct Ownership Interest (100%) Mar 10, 2021

Owned or controlled facilities with NPI records 3

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 3

Facilities that share an organizational owner with 5% or greater ownership or operational control.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1611187200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1611187200000",
    "number": "1063002202",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "300 20TH AVE N STE 403",
            "city": "NASHVILLE",
            "state": "TN",
            "postal_code": "372035180",
            "telephone_number": "615-289-3257"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "155 HEALTH WAY STE 2",
            "city": "MCMINNVILLE",
            "state": "TN",
            "postal_code": "371102668",
            "telephone_number": "931-473-4214"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SAINT THOMAS RIVER PARK HOSPITAL, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SAINT THOMAS RIVER PARK HOSPITAL, LLC",
        "enumeration_date": "2021-01-21",
        "last_updated": "2021-01-21",
        "certification_date": "2021-01-21",
        "status": "A",
        "authorized_official_last_name": "GARRETT",
        "authorized_official_first_name": "CANDACE",
        "authorized_official_title_or_position": "MANAGER OF BUSINESS OPERATIONS",
        "authorized_official_telephone_number": "615-290-7184"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Ascension Medical Group Saint Thomas Woodlee Family Practice",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in McMinnville, TN

Sources for this page

Verify at the official NPI Registry.